Chapter 24 of Psychiatric Mental Health Nursing is devoted to a discussion of "Survivors of Violence and Abuse". While a number of NANDA diagnoses refer to violence, violence itself is not regarded as a psychiatric disorder under DSM criteria. Although many violent persons do have psychiatric disorders, violence is not infrequently perpetrated by normal individuals who find themselves in situations which provoke (or as in the case of war, demand) violent behavior. Certain aspects of violence are considered throughout the textbook. For example, we note that psychiatric clients may occasionally behave violently (p. 10), and we devote several pages to Antisocial Personality Disorder - a disorder in which violent behavior may frequently occur (pp. 362-3). We also discuss the use of restraints and verbal de-escalation in dealing with angry and potentially violent individuals (pp. 725-6). A Nursing Tip on page 725 offers insights for care providers on "Assessing the Risk of Violence." Still, some readers may want a more structured approach to understanding the nature of aggressive or violent behavior and certain contemporary manifestations such as Workplace Violence. This electronic "chapter" is intended to provide that approach to students and instructors alike.

What is violent behavior?

At times, everyone feels anger, an intense emotional experience which combines affective content ("feeling angry") with strong physiological responses (increased heart rate and respirations, piloerection, muscle tension). The experience of anger is closely related to the experience of anxiety, but it emphasizes the "fight" aspect of the "flight or fight" response to threatening or fear-provoking situations. Often angry sensations pass quickly out of consciousness, but not infrequently we find ourselves expressing anger through verbal or non-verbal responses: we may raise our voice or make a seemingly-threatening gesture. The expression of emotion in this way may be healthy, but in expressing emotion we run a risk of crossing an ill-defined line from emotional expression into hostile/violent behavior. Courts have, in recent years, sometimes taken the position that an individual who feels threatened by words or gestures has truly been harassed or abused, even if no physical harm has occurred. When anger is accompanied by threatening physical contact such as shoving, grabbing, or even hitting, then it can clearly be described as having led to violent behavior. Even less vigorous behavior that is perceived as hostile or intimidating can open the perpetrator to legal action. While anger and its expression are universal human experiences, an equally common human experience is the control of anger. Most of us have the ability to keep our anger from escalating into full-scale violence: we may express anger, but we do it only in socially-acceptable ways. Cultures differ in the degree to which overt expression of anger is allowed, and part of growing up in a culture is learning how much angry expression to allow and how much to suppress.

Merely suppressing anger, unless there is some other way it can be defused, does not resolve the strong feelings involved. Many persons use techniques of "passive aggressivity" to express anger without showing the outward manifestations of aggression. Passive aggressive behavior is very common, and since it is actually a form of aggression may lead to escalating or violent responses in others to whom it is directed. Even when the response is nonviolent, the passive aggressive individual may become anxious or depressed as a result of turning anger inward rather than allowing it healthy expression.

When either aggressive or passive aggressive personalities are very strongly developed, a DSM personality disorder may be present. Personality disorders are discussed in Chapter 16 and include Paranoid Personality Disorder, Antisocial Personality Disorder, and Passive Aggressive Personality Disorder; each of these three conditions is often associated with some degree of aggressive or violent behavior.

Psychiatric nurses will not infrequently encounter situations in which anger is expressed in ways that lead to violence or aggression. Sometimes that anger may have already led to personal injury or may put others (including the angry person) at risk for subsequent injury, or even death. Occasionally the nurse himself is at risk for injury when he becomes the target - sometimes seemingly unprovoked - of a client's (or even a colleague's) anger. The World Wide Web has a number of "case reports" of violent situations in which nurses have found themselves. Some of these may be disturbing for students to read, and - as is true throughout the WWW - none has been checked for factual accuracy.

Violence occurs in many interpersonal contexts and may range in severity from verbal harassment to lethal physical abuse. While the following categories of violence are neither exhaustive nor mutually exclusive, they provide a useful framework for understanding violent behavior. Violence may (and does) occur: in families, with sexual content as with harassment or rape, as part of another crime such as robbery, in association with organized antisocial behavior such as gang activity, as an expression of religious, ethnic, racial, or other intolerance, as state-sanctioned activity including war, torture, and capital punishment, in response to social stresses in settings such as highways, health care organizations, and other workplaces.

What are the Psychiatric and Nursing Theories that explain violence?

Psychoanalytic theory has tended to view aggression and violence in terms of frustrated drives and impulses. When a psychological drive is frustrated, then aggression or violence may occur. This is particularly likely when the individual feels threatened, and in particular feels as if he or she is devalued. Psychoanalysts refer to narcissistic rage when individuals try to preserve self dignity by reacting violently against others. Psychiatrist James Gilligan has written an eloquent book about prisons in which he emphasizes the strong sense of shame and personal inadequacy that, as a forensic psychoanalyst, he frequently found in a career evaluating violent offenders. From a similar perspective, Dr. Michael Diamond has written a lengthy essay on the psychoanalytic underpinnings of workplace violence, a topic to which this article will return.

Other psychological theories of violence suggest that it is an expression of learned behavior. In this model, children learn to be violent growing up in homes where the expression of violence is normative. Their normal pre-adolescent learning and development does not foster learning techniques for conflict resolution or de-escalation of violent impulses. When these patterns come into conflict with social norms requiring more controlled behavior, then violence may result. There is a variety of theories based on these ideas, but all have at their core the concept that violent behavior is based on learning and an unfavorable sociocultural environment.

One of the important contemporary questions related to violence is whethe? media emphasis on violent behavior, especially on television, itself leads to violence. The evidence is still in some dispute. The American Academy of Child and Adolescent Psychiatry has concluded that viewed television violence does have detrimental effects on children, at least causing them to be more tolerant of violence. The Psychiatry Academy also concluded that television violence contributes "significantly" to aggressive or violent behavior in children and adolescents. Despite this negative conclusion, the Academy stops short of calling for changes in programming. The American Academy of Pediatrics - a much larger organization representing nearly all doctors who specialize in the care of children and adolescents - similarly accepts that television violence may affect behavior, but primarily calls on parents to monitor their children's television watching. Parents are entreated to ensure that children "know that violence on TV and in the movies is not real" so that they will not assume that all conflicts need to be settled by lethal means. The Academy's Committee on Communications has taken a somewhat more activist view of this topic, and after summarizing very usefully the conflicting data on media violence and violent behavior, urges pediatricians to "strongly urge networks to avoid programming with the gratuitous depiction of weapons and to carry programming that depicts the consequences that violence can have on family and society." Whether this kind of strong urging will have an effect on the media remains to be seen.

Is Violence a crime or a psychiatric disorder?

Much overtly violent behavior is illegal and may result in prosecution and punishment. As the American Psychiatric Association observes, many laypersons associate mental illness with criminal behavior even though the facts are quite the contrary: few mentally ill persons are violent, and the majority of violent crimes are committed by persons who are not mentally ill. There is a close interaction between mental health professionals and the criminal justice system. Psychiatrists and psychiatric nurses are often asked to predict whether a given individual is likely to be violent, to assess whether a person accused of violent crime is psychologically competent to stand trial, and to provide care for a minority of psychiatric clients who may be at risk for violent behavior in health care (or other) settings. Courts commonly seek psychiatric and psychological expertise, while psychiatric nurses occasionally require assistance from police and courts in protecting others - including fellow workers. When confrontations threaten escalation to violence, psychiatric and nursing experts are often called to emergency rooms or other health care settings in an attempt to restore calm and prevent further escalation. As a result, violence has in recent years come to be seen as psychiatrically-related, even when no explicit psychiatric diagnosis is given. Epidemiologists have looked carefully at handgun-related violence, drug-related violence, and violent juvenile crime in an effort to better understand the settings in which such violence occurs. While violent behavior is frequently illegal, it has increasingly become of significant interest and importance to psychiatric mental health practice. Psychiatric nurses and physicians can rarely predict who will become violent, but they can often identify situations with a high risk for the development of violence. Like many other criminal activities, violence can often be anticipated and prevented.

Why are People Violent?

This question has no easy or definitive answer, but violence seems to occur in nearly all human societies. Violence predominantly involves men. Even excluding war (where the majority of perpetrators are men), victims and perpetrators of violence world-wide are disproportionately males in their teens and twenties. There is certainly evidence that correlates testosterone levels with violent behavior in certain populations (including female prison inmates). While assigning cause and effect to such findings is difficult, it does seem likely that endocrine factors combine with neurological pathways in generating violent behavior. Chapter 3 of this text discusses the important role that researchers have found for the limbic system in generating emotionally mediated behavior ( p. 59). In the 1930s Walter Hess carried out experiments which eventually earned him the Nobel Prize. He discovered that electrical stimulation of a cat's hypothalamus could produce a condition that had been called sham rage: the cat behaves aggressively with little or no provocation. Other investigators had discovered that sham rage could be produced by surgically disconnecting the hypothalamus from its higher suppressive centers.

Neuroscientists currently believe that many human (and animal) responses are innately patterned by the hypothalamus, but typically suppressed or "turned off" when - as is usual in ordinary human interaction - they are unnecessary. This concept is somewhat different from a once-popular theory that humans have well-developed aggressive instincts. The current neurophysiological model of aggression suggests that, at least in cats, aggressive behavior is initially triggered by visual and other sensory stimuli. To result in aggression, these stimuli require the presence of a strong level of hypothalamic activation. The combination of sensory stimulus and hypothalamic activation results in activation of regions in the parietal, temporal, and frontal cortices which in turn produce cortically patterned behavior that we recognize as cat aggression - an "attack response." Not all cats have high levels of hypothalamic activation, and when the hypothalamus is suppressed stimuli do not produce an attack response. Both hormones and the brain's limbic system (see p. 59) may act to inhibit the hypothalamus so that the attack response is normally suppressed. In this model, aggression results when there is an absence of inhibitory influences from the limbic system or from the endocrine system (probably including neurotransmitters).

Many years of such cat studies lead to a strong scientific belief that aggression in cats is patterned by the cerebral cortex but driven by the hypothalamus; stimulatory activity in the hypothalamus in turn is modified both by the limbic system and by circulating hormone levels. There is as yet no direct evidence that such a mechanism operates in human beings. Scientists have long sought specific neurologic abnormalities which might explain violent human behavior, but the evidence for these has generally been at best equivocal. Recent data using PET scanning does seem to show that certain violent individuals may have unusual patterns of brain metabolism, involving limbic system brain centers such as the medial temporal lobe and amygdala. These findings might suggest an anatomic basis for decreased limbic stimulation, leading to an under-suppressed hypothalamus and hence - as in cats - an overactive rage response to everyday stimuli. The human evidence is suggestive, but remains only speculative. In contrast, the cat model seems quite well established and after more than 50 years continues to guide human researchers.

There has been some evidence - disputed by many - that violence may occur more commonly in some families, and that in these families both genetic and environmental factors may interact to produce aggressive behavior. Recent evidence suggests that, at least in mice, genetic factors may play a role in aggressive behavior. These studies show that mice bred to be deficient in a gene that synthesizes the neurotransmitter nitric oxide have markedly exaggerated aggressive behavioral responses. Intriguingly, these responses can be mimicked by pharmacological treatment that lowers brain nitric oxide synthesis. This very interesting research suggests that both genetics and the effects of drugs may have a comparable influence on aggressive behavior. In these studies it appears that hormonal influences may also be involved because only male mice were affected. Once again, whether there is any relevance to human aggression is unclear, but this genetic model offers potentially useful insights into the roles that both genetic and environmental factors may play in the expression of violent and aggressive behavior.

Workplace Violence

In recent years there has been in increased interest in Workplace Violence, probably prompted in part by significant media attention. There is little doubt, however, that violence in the workplace is a serious public health concern. As the American workplace becomes physically safer, relatively rare events such as violence become statistically more important as causes of occupational death and disability. Currently, homicide is one of the leading causes of occupational death. The U.S. Bureau of Justice has compiled statistics on workplace crime and theft. These data, based on studies done from 1987-92, suggest that crime not infrequently occurs at workplaces - perhaps not surprising given that record numbers of Americans are presently spending large portions of their lives at work. Most of the crimes did not result in injuries, less than half were reported to public authorities, and many - especially when the victims were women - were perpetrated by persons known to the victim - often a spouse or significant other.

There are an average of 20 workplace deaths each week, but over the vast majority of these occur in the setting of other criminal activity - most commonly robbery - that occurs at the workplace. Less than 10% of workplace deaths are accounted for by the kind of employee "revenge killing" that the public has come to associate with the concept of violence at work.(http://www.cdc.gov/niosh/violfs.html) This picture of Workplace Violence suggests that overall it may not differ greatly from violence as it currently exists throughout American society. Nonetheless, there are specific aspects of violence at the workplace that have attracted the attention of the media, of employers, and of the government: in particular the character of some workplace violence is unique, and it may result in serious harm or death.

Media attention has focused on a number of dramatic fatal events involving the U.S. Postal Service, and the term "going postal" has found its way into slang usage as a description of becoming unpredictably violent. Prominent episodes of workplace violence have been characterized by their lethality, often involving victims unrelated to the perceived grievance of a revenge-seeking worker. Firearms are almost invariably involved, and the event typically has ended in the suicide or killing of the perpetrator. While the overall risk of such severe workplace violence is quite low, there have been strong pressures to reduce the incidence. Employee-associated workplace violence has most commonly been perpetrated by a disgruntled employee or former employee who seeks revenge for a real or perceived supervisory injustice. The following document appears in a WWW forum on violence in Nursing:

The ultimate in workplace violence has finally hit my sleepy little South Carolina town. Last Friday, an unhappy billing clerk pumped 2 bullets into the head of her supervisor at the Occupational Health Clinic. I know the workplace violence you discuss is usually on a more personal level (other behaviors, etc.) This was a well known, and much beloved 44 year old woman who is very much a part of this community and its health care system. She was a former emergency room clerk--used to seeing it all. She is a friend of the hospital, the physicians and nurses, and the police because of her ER job. SHE IS THE SHOOTER. The man she murdered was a relatively new manager brought in to manage the facility after it was sold this spring.

Just last Monday, I had a meeting with my boss about incorporating workplace violence education into the OSHA and Safety training program. How timely!

Just thought you might want some more info for your site and future discussion-- my biggest fear is that WE WILL GET OVER IT, until it happens next time.

While this case involves only one individual, and the perpetrator was (unusually) a woman, it clearly took place in a health care setting and was almost certainly related to a perceived grievance. Like other similar incidents, it appears that the woman who committed murder had planned her crime. The murder did not occur in the context of escalating anger during a confrontation.

Can Workplace Violence be prevented?

The National Institute for Occupational Safety and Health (NIOSH) has published guidelines on preventing violence in the workplace, guidelines ironically referred to in the nurse's web submission quoted above. The NIOSH guidelines recognize that the majority of workplace violence is either associated with robbery (and hence is associated with money-handling, solitary work, or providing services such as pizza delivery where the recipient is unknown) or derives from working with persons who might be anticipated to be potentially violent: emergency room or psychiatric clients, known criminals. The guidelines offer little in the way of specific prevention activities, and - with the exception of bullet-proof Kevlar vests which are said to have saved 1800 police lives - there is no empirical evidence presented that any specific interventions reduce the risk of violence or the severity of its outcome. The guidelines do suggest a "zero tolerance" policy toward threats of violence and "increasing the number of staff on duty" in health care settings. They also endorse training in crisis management and anger deescalation.

The International Association of Chiefs of Police has developed a comprehensive training plan for the prevention of workplace violence. Their document includes several case studies that emphasize the relevance of preventive measures. Prevention involves a combination of careful preemployment screening, review of internal security procedures, personnel management training, employee assistance programs, and early response to any kind of threat or "inappropriate behavior". As the Chiefs make clear, an episode of workplace violence is a major crisis for a corporation, and as such it puts employees at risk for post-traumatic stress disorder. The issues involved with response to crisis are discussed at some length in Chapter 9 of Psychiatric Mental Health Nursing.

Kim and Sobourin have addressed the prevention of workplace violence in health care facilities. These authors recommend swift response to any perceived threat, an approach which - at least anecdotally - can prevent loss of life. Kim and Sobourin emphasize a common sense approach to the physical worksite to reduce the risks of violence. Health care personnel must always have a ready escape route so that they cannot become trapped with a potentially dangerous individual. Rehearsal and advance planning are important to prevent and respond to workplace violence just as they are to respond to the more "natural" threats of fire, earthquake, or tornado. Nurses and other health care personnel must be helped to recognize situations that have inherent risk for escalation. The guidelines in chapter 30 (p. 725) are of value. One company offering training in violence prevention suggests "Ten Tips for Crisis Prevention":

1. Be empathic.

2. Clarify messages.

3. Respect personal space.

4. Be aware of body position.

5. Permit verbal venting when possible.

6. Set and enforce reasonable limits.

7. Avoid overreacting.

8. Use physical techniques as a last resort.

9. Ignore challenge.

10. Keep your nonverbal cues nonthreatening.

By remaining alert to the possibility of workplace violence, by rehearsing responses to violence before it happens, and by working with others to maintain a "zero tolerance" for hostility or other seemingly-minor forms of harassment, the nurse can help ensure maximum safety for him/herself and other fellow workers and clients.

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